F0686

D

Failure to Timely Assess and Treat Unstageable Sacral Pressure Ulcer

Glen Mills, Pennsylvania Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to comprehensively assess and timely treat an unstageable sacral pressure ulcer for one resident. The facility’s pressure ulcer policy required staff to examine the skin of new admissions and document a full pressure sore assessment, including location, stage, measurements (length, width, depth), exudate, and necrotic tissue. Hospital records dated December 28, 2025, showed the resident was admitted with an unstageable sacral wound that had been treated with a wound VAC and dressing changes three times weekly. On admission, the facility’s skin assessment documented an unstageable sacral pressure ulcer but did not include wound measurements, the presence or percentage of slough, or the presence of exudate, contrary to facility policy.

Further record review showed that the wound VAC treatment ordered at the hospital was not initiated upon admission, as there was no evidence of a wound VAC order on the January 2026 TAR. A physician’s progress note dated January 6, 2026, indicated the wound VAC was being held due to a large amount of slough, and a new order was written to cleanse the sacral wound with NSS, apply medical honey, and cover with a dry dressing every shift. However, the TAR showed that no sacral wound treatment was documented until January 7, 2026, two days after the unstageable sacral ulcer was identified on admission. A wound consult on January 7, 2026, documented the sacral wound as unstageable, measuring 6.8 x 7.7 x 1.0 cm with 60% slough and undermining from 6 to 7 o’clock. In an interview, the DON confirmed that the resident’s unstageable sacral wound was not comprehensively assessed until the wound physician visit on January 7, 2026, and that there was no documented evidence of wound treatment before that date.